Provider Demographics
NPI:1669876561
Name:REILLY, KEGAN (PA-C)
Entity type:Individual
Prefix:
First Name:KEGAN
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 OAK RIDGE TPKE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-7177
Mailing Address - Country:US
Mailing Address - Phone:865-482-2129
Mailing Address - Fax:865-482-4036
Practice Address - Street 1:599 OAK RIDGE TPKE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-7177
Practice Address - Country:US
Practice Address - Phone:865-482-2129
Practice Address - Fax:865-482-4036
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN3232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant